Cerebrovascular disease (CVA / Stroke)

1. Cerebrovascular disease (CVA, Stroke) Submitted to AskTheNeurologist.Com in 2007 Author Anon.

4. CVA Epidural Ischaemic Haemorrhagic Subdural SAH Intracerebral Thrombosis Embolus Carotid / VB Cardiac Aortic arch

5. Bleed vs Ischaemia Clear vascular territory No obvious territory Herniation rare / late Early signs of herniation Consciousness relatively preserved ( variable) Consciousness usually impaired if large Moderate / no headache Severe headache Acute or hyperacute Hyperacute Ischaemia Bleed

19. Case 55 year old man with negligible risk factors for cerebrovascular disease Presented to Hadassah Ein Kerem ER with acute, progressive left-sided weakness and right-sided headache 2 days prior to admission felt sudden onset of sharp, right – sided headache associated with left arm numbness and mild articulation difficulty; resolved spontaneously over minutes On morning of admission, recurrence of sharp, severe right sided headache (without pulsatile characteristics) associated with left arm numbness and articulation difficulty

20. Examination Fully conscious & orientated, no neck stiffness Speech Dysarthric Left central facial weakness - Cranial nerves otherwise intact Mild right upper limb global weakness (4/5) Power preserved in lower limbs Reflexes symmetrical with no pyramidal signs Hypoaesthesia left arm Rest of neurological examination unremarkable with no evidence of neglect

21. Diffusion Perfusion Mismatch On MRI Diffusion MRI Perfusion MRI

22. Absent RICA on MRA

23. Pre-Stent Angiography String Sign Parenchymography phase

24. Angioplasty and Stenting Post angioplasty - aneurysm After 1st stent After 3rd stent

25. Comparison of pre and post –stent Angiogram

26. Progress in ER Over period of 2 hours deterioration with marked exacerbation of dysarthria and facial weakness, exacerbation of left arm weakness to 3/5 and appearance of left leg weakness 4-/5 with a left Babinski sign

27. Following procedure Immediately following procedure noticeable improvement in dysarthria and left sided weakness Treatment commenced with LMW heparin, aspirin and clopidogrel. On following morning neurological examination had returned to that noted on arrival to ER: Mild dysarthria with left facial weakness Left arm 4/5 Left leg in tact

28. Follow – up Patient discharged on Aspirin 325mg, Clopidogrel 75mg Trans-cranial Doppler and follow-up MRA revealed patency and normal flow in all cervical arteries Follow-up MRI revealed no progression of infarct Patient responded well to rehabilitation and recovered all function being left with mild dysarthr i a, left arm sensory complaints and facial weakness

29. Submitted to AskTheNeurologist.Com in 2007 Author Anon.